Dr. Clemens has been working with consumer education, public relations, and legislative efforts dealing with changes in health care financing since 1979. He was former Chair of the Insurance, and, later, Economic Affairs Committees of the Ohio Psychiatric Association, and is now President-Elect.
Currently President of the Cleveland Psychoanalytic Society, and Coordinator of Cleveland's Mental Health and Substance Abuse Task Force, Dr. Clemens was recently appointed to the APA's new Committee on Marketing and Financing, overseeing the National Education Program.
Between patient hours the practicing psychoanalyst may occasionally cast a glance or two at the dismal news about the economics of health care delivery appearing quite regularly in Psychiatric News or the American Medical Association News. If there is an empty hour or two during the day, the psychoanalyst may look upon the news with considerably more uncertainty and concern about the future.
The patterns of financing and delivering health care services are changing drastically. Many cost-containment measures that underlie these changes have been selectively focused on psychiatric patients, especially those in need of intensive or long-term treatment. The impact has been especially felt in some parts of the country suffering major cutbacks in the last decade after previously enjoying liberal coverage for full psychoanalytic treatment.
Psychoanalysis has been caught in a pincers movement. On the one hand is specific, discriminatory cutting of benefits that support psychiatric treatment. On the other is a growing trend towards organized practice settings and prepaid care, as opposed to the independent, solo, fee-for-service practice that is largely the environment in which psychoanalysis thrives.
Encouraged by Federal legislation, the health maintenance organizations (HMOs) have taken a steadily increasing share of the market, which is estimated to cover 26 million Americans by 1988 and approaches 40% or more in a few cities. More recently, the trend towards self-insurance by major employers, a slackening of anti-trust regulation, and greatly reduced restrictions on advertising and marketing by physicians and hospitals have all led to the growth of preferred provider organizations (PPOs) and a rapidly escalating competitive marketplace in which traditional group insurance such as Blue Cross/Blue Shield takes a beating. The Blues and the commercial carriers are getting into this melee by developing their own alternative delivery systems (ADSs), as are hospitals, medical societies, and just about any group that wants to try its hand at the risky business of providing health insurance.
Almost invariably these competitive offerings have very sparse coverage for mental illness. Limits of 30 hospital days and 20 outpatient visits per year are fairly standard. In addition the plans restrict access to certain providers who are either on the salaried staff of a closed-panel HMO or members of independent practice associations (IPAs) and PPOs. Often they depend heavily on nonmedical professionals for what mental health care they do provide.
The free flow of patients by self-choice or referral to subspecialists particularly qualified to treat certain kinds of difficulties, such as psychoanalysts for neurotic and personality disorders, usually is not possible within such a system. Often the physicians share in the risk the ADS takes on. More than one of these programs have gone bankrupt, so the onus is now on the primary physicians to limit the amount of care given. Naturally this favors short-term and biological treatment approaches.
In addition some of these systems have a so-called gatekeeper—a primary care physician who must authorize all services rendered to the patients under the plan, especially hospitalization and referral to specialists. Frequently the primary care physicians are paid prospectively on a capitation basis—so much per month per “head.” The gatekeepers may have an added economic incentive not to refer and not to hospitalize, because at the end of each year, they share in what is left of certain funds reserved for those purposes. The ethics of the capitation/gatekeeper system geared to rationing services, as contrasted to the ethics of the fee-for-service system where the therapist profits by providing services, could be grounds for a great deal of debate.
Mental health management systems are now springing up, competitively contracting with self-insured employers, PPOs, HMOs, etc., to provide all of their mental health services for a capitated monthly fee. Since the express intention is to cut costs and limit “unnecessary” services, and the “case-management” staff is likely to be nonmedical, the outlook for indepth, definitive treatment of major psychiatric disorders in such systems is bleak.
The bottom line economically is that more and more patients are being denied access to the private, free-choice, fee-for-service system in which most psychoanalysts practice. Induced by somewhat lower premiums and encouraged by employers and government, families purchase contracts with the ADSs and then find themselves unexpectedly without resources when serious needs arise for psychiatric services. Some have become the new “psychiatrically indigent.”
The movement towards more and more concentration of practice in organized settings is consistent with the trend described by Paul Starr in his landmark book, The Social Transformation of American Medicine (Basic Books, 1982). He foresaw the steady development of corporate practice of medicine, increasingly dominated by large for-profit organizations in a competitive marketplace. Some have predicted that within a decade or so there will be a half-dozen or dozen nationwide health care systems, from which patients will choose their health care provider. Solo private practice will survive, but with a much smaller share of the patient population than it now has.
It is very tempting to say “nothing.” We all enjoy treating self-paying patients who are highly motivated for change and will make considerable financial sacrifice to achieve what they can in psychoanalysis. What a relief not to deal with insurance forms, or worry about premature withdrawal of third-party reimbursement for analysis, or
seek the delicate balance among confidentiality, protection from intrusion, and meaningful communication for claims review decisions about the medical necessity of treatment! Why not just “cultivate our own garden” and ignore the outside world?
In a recent issue this Newsletter carried several articles about the feasibility of peer review for psychoanalysis. A legitimate and convincing point can be made that disruption of the psychoanalytic process is just too great to make it worth trying to do analytic work under such conditions. But we must face it: despite the fact that many analysts see some patients for relatively low fees, widespread refusal by analysts to be involved in third-party payments and peer review means that most people simply will be denied the substantial benefits of psychoanalytic treatment.
Thus, another pathway is to develop effective review mechanisms allowing appropriate sharing of descriptive information without intruding on the private details of the psychoanalytic work or undermining the patient's confidentiality. Many analysts feel that progress has been made towards this objective and that psychoanalysis under these circumstances is feasible. Since more generous benefits are often linked to claims review, a broader spectrum of the population might then have access to analysis. Recently the Peer Review Committee of the American has developed clarifications of the claims review process with the intention of making review more palatable and clinically appropriate. The membership will soon receive more information about their recommendations. Continued experience in this area must be closely monitored by the American, and well-qualified analysts must be willing to accept the burdens of time and inconvenience that go with being a psychoanalytic peer reviewer.
Psychoanalysts can also become actively involved with their psychiatric and medical organizations—local, state and national—in pursuit of equal and nondiscriminatory coverage for psychiatric illness. Recent court decisions have cleared the way for state laws mandating insurance coverage. Many APA District Branches, and the APA itself, are devoting unprecedented resources to legislative and/or marketing initiatives.
The American seems in effect to have yielded to the APA the task of implementing our aims in the area of government relations and insurance, reasoning that the resources of the APA are much greater than ours and the impact is enhanced by working together with other psychiatrists.
Of course, the APA is made up of many diverse elements, including some influential points of view that advocate delivery of psychiatric service in organized settings, under prepaid plans, with rigid utilization review, etc. These approaches generally are touted as creative, competitive, and responsible ways of dealing with the current situation and of responding to employers' concerns about health-care cost containment. From our point of view, however, they raise alarming questions about access to care and adequacy of the services that result.
So we psychoanalysts need to get in there and make our voices known and heard. To be successful calls for genuine concern about all patients, not just our own. By actively educating other psychiatrists and other physicians about the nature of psychoanalysis and the problems we deal with, we can identify the notion of “remedicalization of psychiatry” as in fact a retreat to biology, and remind others of our proud psychoanalytic heritage within the medical tradition. Our own Association, however, must lead the way both in assessing the unique problems of practicing psychoanalysis in today's perilous environment, and in devising appropriate responses. We cannot leave it to the APA.
In the competitive marketplace, psychoanalysis will have to be visible. It will have to demonstrate in scientific terms that can be generally understood and respected, its therapeutic superiority for certain conditions. Its quality, cost-effectiveness, and uniqueness, while clear to us, will not be accepted at large without effort on our part.
We are tempted to say that the opposition we encounter is based on resistance and unconscious forces, and therefore not susceptible to influence. No doubt such forces play their part. Yet to assume that we are consequently helpless is unduly nihilistic about the possibilities for effective communication; it rationalizes withdrawal and inaction. In fact, such an attitude insults the lay people we must deal with by saying they are inaccessible to reason and solid information. We can no longer afford a posture of splendid isolation.
Are the changes we are seeing an ever-rising tide or a pendulum about to swing? There are some forces working against prepaid, organized settings, particularly those that build their competitive edge on aggressive curtailment of services. There is greater vulnerability to lawsuit, hence higher malpractice premiums, in a system that rations diagnostic investigations and treatment. The economics of health insurance are proving insurmountable for some plans.
The public's own reaction when it fully perceives what is given up by entering a prepaid, closed-panel health care delivery plan has yet to emerge, but any perception of substandard care may drive patients back to traditional insurance, fee-for-service medicine, and free choice of physician. Aided by their employee assistance programs and a growing body of data, employers may be awakening to mental-health needs and the cost of not supporting appropriate care. These thin hopes do not justify inaction on our part; knowledgeable people hold out little promise that the flood will be reversed, and psychoanalysis is particularly vulnerable.
Intriguing questions are whether psychoanalysts can actually participate in prepaid or capitated delivery systems, and whether psychoanalysis proper can be part of what is offered. There is convincing evidence that psychotherapy does reduce utilization of other kinds of medical services, and the cost offset is enough to balance the cost of psychotherapy when limited care is all that is needed. However, full-scale psychoanalysis clearly costs more than it saves at the time, and insurance plans do not care about the long-term prospect for savings.
In a large-scale plan, with careful prospective review being used to select patients most in need of psychoanalysis, it would be feasible to carry a certain number of cases under a “catastrophic” umbrella coverage. (The Federal Employees Health Benefits Plan paid for psychoanalysis for many years, and the psychiatric portion of the health care dollar never exceeded 7-8%.) Some ADSs might find it a marketing advantage to emphasize true quality, including the full range of psychiatric treatment, as a distinctive preferred choice over the “cheapskate” plans.
However, such a plan would have to be protected against the effects of “adverse selection” in which the richer benefits would become a magnet for patients in need of psychoanalysis but otherwise unable to afford it. This would not be a factor were such plans generally available to the population at large so that no one plan would be hard hit.
Some groups at high risk, such as those which include health care professionals, may wish to pay the extra premium for making intensive psychoanalytic treatment available, because of its great worth to the professional effectiveness of the members of that group.
Certain specialized psychoanalytic services, such as analytically grounded treatment for young children, might prove a very appealing addition to an organized health care delivery system. The alternative delivery systems have been accused of “skimming” off the healthy younger families at low risk for medical problems—but such a population is at peak need for psychoanalytic services, and a plan that lacks such services is deficient.
Any attempt to provide psychoanalysis within an alternative delivery system must reckon with certain irreducible conditions. Psychoanalysis cannot exist in an environment more concerned with saving money than with providing truly beneficial services. A valid therapeutic process can only take place if ultimate control of the ongoing treatment rests solely with patient and analyst. Intensive, interactive, concurrent review and intrusive case management techniques are totally incompatible with the open-ended “holding” environment of psychoanalysis.
This is a discouraging picture. It is balanced by knowing that some patients eventually turn away from the empty allure of short-term treatments or endless palliative drug therapy. They come to psychoanalysis with high motivation, willing to do whatever it takes to come to terms with their problems at last. They sense and confirm the validity of psychoanalytic understanding.
Most of us have made major financial sacrifices in order to have the great satisfaction of practicing psychoanalysis, and we shall probably make more. Nevertheless, if third-party payment continues to dwindle away, psychoanalysis will, despite our efforts, come to fit the old caricature of being a luxury for the rich, with its great benefits available only to a favored few. Whether the psychoanalytic profession and the American can act effectively to overcome these trends remains very much an open question. Only great effort by many psychoanalysts across the country will give our patients a fighting chance.